Medical Minute 8-15: Saving a Rock Star's Voice with Lasers

Aerosmith Bassist Tom Hamilton normally slaps the bass in rock songs, but this song is a message to his throat and tongue cancer.

In 2006, Hamilton underwent chemotherapy and radiation for tongue-base cancer, but three years later, his cancer came back and extended into his voice-box. That's when he turned to Doctor Steven Zeitels.

"This is not your classic way, or even traditional way, to try and remove a cancer from the tongue base," said Steven Zeitels, M.D., F.A.C.S.Director, Mass General Hospital Voice Center/Eugene B. Casey Professor at Harvard Medical School.

Since Tom had already undergone radiation and chemotherapy, radical surgery was his only option, but that could leave his voice and breathing passage permanently damaged.

"I was just terrified. I really thought, 'Oh, I am looking at not being able to talk," said Tom Hamilton, Aerosmith Bassist.

Since Doctor Zeitels has had great success treating vocal cord cancer with the green-light KTP laser, Tom decided to be the first person to try the unique approach in the tongue base. The KTP laser emits a green light, which is concentrated in the extra blood running through the cancer.

"Where there is a lot of cancer, there will be a lot of blood. Where there is a lot of blood, there will be a lot combustion so that you are actually watching the tissues burn completely different."

Doctor Zeitels cautions not everyone is a candidate for the unique laser surgery.

"The second I had a tiny bit of consciousness, the first thing I did was make a sound, and it felt normal, and it sounded normal."

A major advantage of the laser is it can be done repeatedly as new benign or malignant lesions are found. Tom feels Doctor Zeitels' laser procedure saved his voice and his life.

"Thank you for helping me win the lottery."

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

BACKGROUND: The National Institutes of Health estimates that 7.5 million Americans have trouble using their voice. The disorders can range from spasms to tumors. The KTP Laser treatment is an innovative laser therapy that can be used for vocal cord cancer. It successfully restores patients' voices without radiotherapy or traditional surgery, which can permanently damage vocal quality. (SOURCE: Annals of Otology, Rhinology, & Laryngology)

TREATMENT: KTP Laser Therapy is a delicate laser technology that allows doctors to treat vocal cord lesions, such as polyps or tumors, as an outpatient treatment without anesthesia. The laser procedure allows patients to be treated without the risk of radiation or damage to the underlying tissue, which better preserves the natural voice. This procedure is especially beneficial for patients with reoccurring conditions that require regular treatment, such as laryngeal papilloma or laryngeal dysplasia. (SOURCE: Emory Health Care)

EARLY RESULTS: The first 22 patients who received pulsed laser treatment for vocal cord cancer were reportedly cancer-free several years after treatment. Some have required second or third laser treatments to remove residual disease, but another benefit of the therapy is that it does not rule out future therapeutic options. Dr. Steven Zeitels estimates that 90 percent of patients with early vocal cord cancer would be candidates for pulsed-KTP laser treatment. (SOURCE: American Broncho-Esophagological Association)

There are several advantages to the KTP Laser Therapy. Some include:• Pulsed-KTP laser therapy allows vocal cord lesions to be removed with minimal damage to vocal fold tissue, thus preserving the natural voice.• It is ideal for patients with reoccurring conditions because it does less damage to the vocal folds, and it can be performed as an outpatient procedure.• The procedure can be performed while a patient is awake. The patient needs only a numbing agent, no general anesthesia and can drive himself home immediately after the procedure.• It replaces the need for traditional inpatient vocal cord surgery, requiring only a couple of hours of patient downtime as opposed to the two days needed for a typical operation under general anesthesia.(SOURCE: Emory Health Care) FOR MORE INFORMATION, PLEASE CONTACT: Melanie WoodworthMass General Hospital Center for Laryngeal Surgery(617) 726-0218voice.center@mgh.harvard.edu

Dr. Steven Marc Zeitels: A laser is a device that is emitting light in specific wavelengths that in surgery can have any number of desired effects to tissues. There are different styles and types of lasers that have different characteristics.

Can you discuss the difference between the original lasers used versus those that have great application for the tissues in the throat?

Dr. Steven Marc Zeitels: The original lasers that were used in the voice box were called carbon dioxide (CO2) lasers. The laser light is absorbed into water. With our current KTP laser the light is absorbed in hemoglobin or blood. These are called angiolytic lasers. These are in fact specialized lasers that were invented in dermatology, but have great application for the voice box as well as the tissues of the throat.

What exactly are these lasers used specifically for?

Dr. Steven Marc Zeitels: The angiolytic lasers emit a wavelength of light that is either yellow or green light. We tend to use the green-light laser, which is the KTP laser. We use it for soft tissues that are abnormal or also have an abnormal blood supply such as cancer. That is a concept of accelerated cancer growth that is dependent on growing its own blood supply is commonly referred to as angiogenesis.

What is so different about Tom’s case specifically?

Dr. Steven Marc Zeitels: We extended our state-of-the-art cancer treatment with the KTP laser, which was pioneered in voice-box cancer. In Tom’s case, the disease was in the upper part of his voice box, however, it traveled into the tongue base. Using the KTP angiolytic laser is not a classic way or even a typical method of trying to remove the cancer from the tongue base.

What would be a typical way of removing cancer in the case of the tongue?

Dr. Steven Marc Zeitels: In the tongue base, you might consider a carbon dioxide laser, but more likely it requires as open neck operation if someone has sustained failure with radiation as well as chemotherapy as was Tom’s situation.

What brought you to the conclusion that you needed to use the green-light KTP laser in order to remove the cancer from the base of Tom’s tongue?

Dr. Steven Marc Zeitels: We have a very successful experience over the span of approximately eight years using the KTP laser in novel and innovative ways for treating the voice box – more so with vocal cords since we had to preserve people’s ability to talk. Some vocal cord cancers became large and moved into the upper part of the voice box, the supraglottic larynx. When Tom came in, he then became a great candidate for this sort of approach for removing cancer, because if not we then had to move to a more invasive and morbid method of surgery. It became a question of ‘should we go down this path,’ which is more reasonable and reserve the more difficult pathway for him should the minimally-invasive laser treatment not be successful. We decided that the endoscopic laser approach was a more prudent initial pathway.

Can you sort of walk us through the steps of how the laser was implemented and what exactly was done in an effort to remove the cancer from the base of the tongue?

Dr. Steven Marc Zeitels: Well, the first thing to know is that you are using a surgical microscope, thus you have intense magnification of the tissues. We used a variety of specialized laryngoscopes (endoscopes), which I had designed and patented over the past 20 years. These laryngoscopic instruments provide exceptional exposure of the cancer that must be removed. The laser light is introduced through the laryngoscope by means of a glass fiber that is less than .5 mm. When treating the tumor, we are observe how to light interfaces with the tissue. Because of the concept of angiogenesis, where there is a tumor (cancer) there is more blood so that the angiolytic green-light KTP laser will preferentially heat and destroy the tumor as compared to the patient’s normal tissue. In other words, normal tissue will actually take in the light differently since there is less blood as compared with tumors.

When you say, “. . . take in the light differently . . .” are you referring to a change of color?

Dr. Steven Marc Zeitels: Yes. Well, actually where there is cancer there will be a lot of blood. Where there is a lot of blood there will be a lot of combustion, so that you are watching the tissues actually burn completely different as if you had a fire in an oxygen-rich atmosphere or if there wasn’t a lot of oxygen. Here, in this particular situation with the green KTP laser, it actually is attracted to the hemoglobin in the blood, and if there is more blood in the tumor you will see less carbon and combustion so that you will know that you are getting back to normal tissue. So you have two things to use: not only the magnification that you observe through the microscope, but also you are observing how the tissue is reacting under magnification.

So through the aforementioned procedure, you as a doctor will be able to identify where the cancer is most prominent?

Dr. Steven Marc Zeitels: Yes. To confirm that, then you will do something called frozen sections. You will take a piece of tissue there and send it to a pathologist who can confirm that you are beyond the tumor. The other thing that is an advantage is that you can calibrate the lasers so that you don’t get a lot of extra burning of the margin so that you can send it to the pathologist, and they can read it and won’t come back to you saying, “All I see here is burnt tissue.”

So in essence, you are able to give them a clean margin of error without the tissue being burned?

Dr. Steven Marc Zeitels: Exactly. You are given a clean margin around the cancer, because there is no turning back if you use this approach – if you haven’t eradicated all of the cancer, chances are it will return in a few months.

Are you the only doctor in the entire world right now utilizing these methods of treatment?

Dr. Steven Marc Zeitels: I would say that in the voice box now it is likely only our trainees from the Mass General Hospital. We have a specialized fellowship program for people after they have already completed residency in head and neck surgery. I would say now, since the commencement of our facilities using this laser for cancer about eight years ago, we have published in the Peer Review Literature that I suspect a number of our trainees have expanded on their education and are continuing to perform these sorts of innovative procedures for the treatment of cancer.What about in regards to using these methods in the area of tongue cancer specifically?

Dr. Steven Marc Zeitels: That is still the exception. We would typically use the endoscopic laser technique prior to the chemotherapy and radiation treatments. So again, this is done to avoid a more open and morbid operation if we can. If someone came in with tongue cancer, we would be predisposed to removing as much as possible without deteriorating the patient’s voice or swallowing function, after which we would then send them for their further treatment. This is not standard nor is there substantial information and literature regarding this because there is not a lot of funding to support this type of study. However, in our hands, which is very focused for our patients, we would remove most of what we could transorally (through the mouth), which is very avant-garde, and then we would send that patient in for radiation treatment with very little or no discernable cancer. This concept was really explored by my teachers in the early 1970’s when they initially introduced lasers into medicine.

When did you realize (your ‘aha’ moment if you will) that the green KTP laser could be used to eliminate the existing cancer at the base of Tom’s tongue?

Dr. Steven Marc Zeitels: Tom is an extremely intelligent individual that in all honesty can handle a lot of information. He had already learned about the traditional open surgical salvage approaches. The advantage in my practice, nevertheless, is that when people come to me for treatment . . . it often times means they are looking for the unconventional. They want to see what may be beyond the standard state-of-the-art technology that other healthcare professionals weren’t offering or knew nothing about. So it has already screened out the people who are willing to entertain the notion of a non-routine procedure. You can’t do an unusual operation if they don’t understand how it is so different, because in that case there wouldn’t be informed consent. Both Tom as well as his wife were familiar with what was state-of-the-art in regards to standard care. I then offered a bit of complexity saying, “Well, we can try this and sort of hold that in reserve.” When I looked at the tumor, where it was and the appearance of it of what it looked like in the office (I wouldn’t know for sure until we were in the operating room), I thought that I could get remove it successfully. The other advantage is given his perfect jaw anatomy in addition to his neck anatomy, I thought that we could use some of our novel instruments and have the exposure to do it. In a different kind of person’s head or neck configuration, I wouldn’t have had the exposure that was evident with Tom. He was the right person intellectually. He was the right patient spiritually. He was the right patient anatomically, and furthermore it was the right tumor.

How did you come to the conclusion that you could approach Tom’s treatment in such an innovative way? I mean, you had to have had some notion before him and his wife walked into your office that under these particular circumstances it could be possible, right?

Dr. Steven Marc Zeitels: Well again, we have done this before in patients before they went into chemotherapy and radiation. We had already done that, so I knew that this approach wasn’t out of the question. The difference here is that you are typically receiving the chemotherapy and radiation treatment after the laser treatment. In Tom’s case, this was it. The laser treatment either worked or it didn’t. The reason that you often times mix chemotherapy with radiation is that they work in concert to increase each other’s effect on the cancer. When we had used the laser approach before, we had all three (the laser procedure, chemotherapy and radiation) working together. If the green KTP laser didn’t work here, that’s it. We wouldn’t have the option of using other treatments.

So Tom had already been through chemotherapy, received little to no benefit, and had to seek out a more nontraditional method, am I correct in saying that?

Dr. Steven Marc Zeitels: Tom’s tumor initially shrunk but then recurred substantially. Since the chemotherapy and radiotherapy didn’t work, he had to move on.

So that is what was so unusual about Tom’s case?

Dr. Steven Marc Zeitels: Correct. The unusual thing about Tom’s case was his willingness and our willingness to use this novel laser treatment approach as a salvage technique after failed chemotherapy and radiotherapy.

If you hadn’t gone through with this treatment, your options would then have become far less, therefore forcing you and Tom into a more invasive and perhaps even life threatening procedure, right?

Dr. Steven Marc Zeitels: Yes. We would have had to cut open his neck and throat placing a breathing tube in his windpipe.

I just want to clarify that he could not have gone through chemotherapy or radiation again because he had already gone through it, correct?

Dr. Steven Marc Zeitels: Yes. He could have had some chemotherapy, but this would be viewed as more palliative rather than curative. If he really had large, open through-the-neck operation, it would have been highly unlikely that he would ever be able to eat again for the fact that he already had lost so much tongue function. He would have now lost a substantial amount of his voice box because the tumor was in it. In all honesty, the chances of him ever eating again would have been well under five percent. Furthermore, he would have required a breathing tube in his neck for quite a long time. Things just aren’t the same anymore when you are forced to cut through all of the soft tissue and nerves present in the neck. To do that operation through the neck, the sensory nerves that feed the area would had to have been cut. In due course, he would have had no sensation when he ate and would end up with pneumonia. He would have, in my opinion, never have been able to eat again. Now, he eats slowly but he gets there. One of the reasons that he is having so much trouble eating now isn’t because of that surgery, nonetheless, but the surgery that followed after the prior tumor and radiation. So if I did his operation to someone who had never had radiation, they would without a doubt be eating normally.

Is there anything that you would like people to know in regards to how you operate and why you implemented such a nontraditional method of treatment in this particular case under these particular circumstances?

Dr. Steven Marc Zeitels: People who are listening to this need to understand that this procedure is not standard. Again, both Tom as well as the staff here were willing to employ rational pioneering treatment approaches that have not been previously done. At the MGH Voice Center, and with our trainees, it is fairly routine to use a green KTP laser to treat voice box cancer, but it is not routine to treat this type of tongue-base cancer. This is something that is very imperative for people to know because a majority of our work relates to saving voice boxes.

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